hammer digit syndrome an evidence based approachschd.ws/hosted_files/ipmafall2016/6e/hammer...

10/21/2016

1

Hammer Digit Syndrome: An Evidence Based Approach

By

Patrick A. DeHeer, DPM

FASPS, FACFAS

Trepel et al. JFAS 1999Preferred Practice Guideline:

Hammer Toe Syndrome01

10/21/2016

2

Defining Terminology

Hammer Toe

Claw Toe Mallet Toe

Overlapping 5th Toe

DigitiQuintiVarus

Clinodactyly

Defining Terminology

10/21/2016

3

Goals and Objectives of Treatment

Relive Pain In & Out of

Shoes

Improve Function

Goals of Diagnosing & Treating

HDS

Reduce Deformity Prevent

Deformity

Progression

Prevent Morbidity

Physician’s Objectives to Accomplish Goals of Diagnosing and Treating HDS

Accurately Diagnose HDS

Determine and initiate the optimal treatment plan, with consideration of overall patient status and needs

Determine the etiologic factors contributing to, and/or exacerbating the deformity

Obtain appropriate consultation when indicated

Inform and educate the patient regarding treatment options

1 2 3

4 5 6 Provide appropriate follow-up and rehabilitation, as necessary

10/21/2016

4

Incidence of HDS

4-14 y/o

M = F

W: 1:3800B: 1:700

31-60 y/o

15-30 y/o 60 + y/o

F 9:M 1

W: 1:100B: 1:33

F 3:M 1

W: 1:10B: 1:9

F 2.5:M 1

W: 1:15B: 1:5

Risk FactorsPes Cavus

Pes Planus

Equinus

Abnormal Metatarsal and/or Digital Length or Position

Neuromuscular Dysfunction

Arthritides

Trauma

Pressure or Deforming Force From Adjacent Digits (i.e. HAV)

Metatarsus Adductus

Hereditary Factors

Biomechanical Dysfunction

Improperly Fitted Shoes and/or Hosiery

10/21/2016

5

Flexor Stabilization 1. Most common etiology2. Flexors tendons are

supinators of RF3. Pronation – fire earlier &

longer to stabalizeMTJ/STJ

4. Late stance phase FDL > Interossei (inefficient in pronated foot)

5. Clinically – excessive gripping of toes in stance with hammering/clawing, adductovarus 5th/4th

digits

Flexor Substitution1. Least common etiology2. FDL > Interossei when

deep posterior lateral muscles substitute for a weak GSC (Achilles Insufficiency)

Non-mechanical1. Isolated HDS is usually

static not dynamic 2. Long toe with retrograde

shoe pressure, hallux under riding adjacent 2nd

toe, ill-fitting shoes, female, advancing age

Extensor Substitution1. EDL > Lumbricales during

swing resulting in deformity

2. Pes Cavus, Neuromuscular Disease

3. Normal 30° DF at MPJ during swing increases to 90°-130°

4. Equinus – FF PF RF EDLs fire earlier & longer during HO

5. Clinically – EDLs bowstring prior to HO, toes are always clawed without varus rotation

01 02

04 03

Etiology

Diagnosis & Evaluation

History1. PMHx2. Surgical Hx3. FSHx4. Medications5. Allergies6. HPI – NALDOCATs7. Type of shoe gear & hosiery

Diagnostic Exams1. X-rays – 3 WB views to

asses deformity2. Laboratory Tests –

metabolic, inflammatory or infectious

3. NCVs/EMG – NM disease4. Lower Extremity Arterial

Exam

Physical Examination1. Comprehensive Lower

Extremity Exama. Lesions/Ulcers/Erythema/

Infectionb. Flexible/Semi-Reducible/

Non-Reducible Deformityc. Secondary Pathology

2. Comprehensive Biomechanical Exam –WB/NWB

H

P

DE

10/21/2016

6

Sequelae of Non-Treatment

Progression of deformities from flexible to rigid

Pain

Digital Clavi

Toenail deformities

Sub MTH HPK

Bursitis/Synovitis

Tendinitis

Gait abnormalities with proximal structural symptoms

Shoe gear limitations

Degenerative joint disease

Ulceration possibly leading to infection

Indications for Treatment

Digital deformity with or without pain

Associated lesion or finding

HPK

Adventitious Bursae

Ulceration

Erythema

Infections

Interdigital maceration/helloma

Biomechanical instability of the toe and adjacent MPJ

Arthrosis of toe and/or related MPJ

10/21/2016

7

Treatment of HDS

Non-Surgical

1. Symptoms controlled conservatively

2. Patient does not desire Sx

3. Poor Sxcandidate

Routine HPK debridement

Monitoring & Living With Deformity

Topical Keraotlytics

Modification of shoe gear/hosiery

Orthodigita

Corticosteroid injections/NSAIDs/Oral Steroids

Orthosis

Treatment of HDS

Surgical Indications

Conservative care unsuccessful, undesirable or impractical

Informed consent of the patient

Deformity involving any combination of MPJ, PIPJ and/or DIPJ documented by radiographs and/or physical examination

Pain/deformity/altered function affecting daily life

10/21/2016

8

Complications Associated with HDS Surgery

Persistent edema

Recurrence of deformity

Residual pain

Excessive stiffness

Less common complications:NumbnessFlail toeSymptomatic osseous regrowthMalpositionMalunion/nonunionImplant fatigue/failure/intolerance InfectionVascular impairment Gangrene

Flexor Digitorum Longus Transfer: Flexible/Semi-Flexible/Semi-Rigid HDS Deformities

02

10/21/2016

9

Losa Iglesias et al. JAPMA 2012Meta-analysis of Flexor Tendon Transfer for the Correction of Lesser

Toe Deformities

Methods Results Results

1. 203 citations → 112 articles reviewed → 17 articles met study criteria

2. 515 procedures3. Mean F/U = 54.21

mos. ± 20.64 mos.4. Mean age = 51.01

± 9.76

1. Crude patient satisfaction = 86.7% (95% confidence interval, 81.7%-90.5%)

2. Low grade of heterogeneity -no influence of individual study

1. High quality adjusted study patient satisfaction = 91.8% (NS)

2. Priori source heterogeneity adjustments → NS

FDL transfer rationale – substitutes for lost intrinsic muscle function restoring digital function while removing deforming force of FDL

Primary Complication - stiffness (up to 60% reported by Pyper (alone did not detract from patient overall satisfaction); other reasons for poor results (excessive PIPJ/MPJ contracture, marked cavus deformity, RA and Pes

Planus)

Bayod et al. JAPMA 2013Stress at the Second Metatarsal Bone After Correction of Hammertoe and

Claw Toe Deformity: A Finite Element Using an Anatomical Model

10/21/2016

10

Bayod et al. JAPMA 2013Stress at the Second Metatarsal Bone After Correction of Hammertoe and

Claw Toe Deformity: A Finite Element Using an Anatomical Model

“There is a biomechanical advantage to performing FDLT or FDBT instead of PIPJA to surgically treat a hammertoe or claw toe deformity. In addition, tensile strain at the dorsal aspect of the second metatarsal bone when performing PIPJA increases the risk of metatarsalgia or stress fracture in patients at risk. “

Arthroplasty vs. Arthrodesis: Semi-Rigid/Rigid HDS Deformities

03

10/21/2016

11

Schrier et al. FAI 2016Lesser Toe PIP Joint Resection Versus PIP Joint Fusion: A

Randomized Clinical Trial

Level of Evidence: Level II, lesser quality RCT or prospective comparative study

Both groups had K-wire fixation across MPJ x 4-6 weeks

Both groups P/O FWB in surgical shoe

Schrier et al. FAI 2016Lesser Toe PIP Joint Resection Versus PIP Joint Fusion: A Randomized

Clinical Trial

Significant improvement in all categories pre-op to 3/12 moths P/O

No significant difference between 3 months & 12 moths P/O

No main effect between groups could be detected

No interaction effects could be demonstrated

10/21/2016

12

Schrier et al. FAI 2016Lesser Toe PIP Joint Resection Versus PIP Joint Fusion: A Randomized

Clinical Trial

Significant main effect with hallux in FFI B but not FFI C

No main effect for VAS pain or AOFAS groups with hallux

Patients with 1st ray correction had ↑ FFI B & FFI C scores to those w/o

This 1st ray correction effect was equal between the 2 groups



Complications

12/26 Resection 18/29 Fusion

Total 30 of 55

11 K-wire related –

no difference b/w groups

6 Floating toes (4

resection)

6 Maligned toes (4

resection)

2 Sensory deficit

1 Infection

1 Recurrence

1 Pseudo-

Arthrosis

1 Superficial

skin necrosis

10/21/2016

13



PIPJ fusion resulted in a better alignment on the sagittal view, compared to PIPJ resection Second PIPJ alignment in an AP view, no significant effects were found7 of 29 fusions resulted in nonunion with 1 symptomaticMPJ release did not influence of outcome of SP P/O PIPJ alignment

Sung et al. Foot & Ankle Specialist 2014Retrospective Comparative Study of Operative Repair of

Hammer Deformity

10/21/2016

14


Hammer Deformity


Hammer Deformity

Average age = 60.0 ± 11.4Average F/U = 53.8 mos. ± 32 mos.

125 other HDS repairs53 lesser MT osteotomies 48 HAV corrections

7 TB Sxs4 neuromas2 – 1st MPJ implants 1 – 1st MPJ arthrodesis

43 cases MPJ releases, extensor tenotomy and/or MT osteotomy

10/21/2016

15


Hammer Deformity

Arthroplasty25 (56%)RecurrenceTransfer callusMetatarsalgiaBlistersUlcers17 (38%) Revisional Sx

Arthrodesis17 (42%)Painful hardwareNonunionTransfer callusesCellulitisBone spursUlcer

ArthrodesisRecurrenceDVT6 (15%) Revisional Sx

Implant17 (35%)NumbnessDehiscenceImplant deviation MetatarsalgiaCellulitis4 (10%) Revisional Sx

Methods of Fixation 04

10/21/2016

16

Kramer et al. FAI 2015Hammer Toe Correction With K-Wire Fixation

709 F : 167 MAverage age = 57.5 y/oAverage F/U = 20.8 mos.

2nd – 10113rd – 6504th – 5615th – 476


393 HV corrections (35.2%)213 1st MPJ fusions (19.1%)89 Kellers(8.0%) 45 Hallux IPJ fusions (4.0%)22 HL Sx(2.0%)

67 TB Sx(6.0%)31 Flatfoot Sx(2.8%)31 CavovarusSx (2.8%)26 Midfoot fusions (2.3%)21 Triple arthrodesis (1.9%)

10/21/2016

17



K-wires left in average of 39.2 days 118 (4.4%) K-wires required early removal 150 (5.6%) symptomatic recurrence of HDS with 94 (3.5%) requiring revisional Sx Asymptomatic or minimally symptomatic malalignment was noted in 55 toes (2.0%) at

final follow-up 9 pin tract infections (0.3%) P/O Abx required in 124 of 1115 (11.1%) Vascular compromise occurred in 16 toes (0.6%) with 10 (0.4%) requiring amputation (8

additional amputations for other reasons) 2 toes with broken pins (0.1%), pin migration 94 toes (3.5%) with 59 (2.9%) completely

extruded The expected rates and rate ratios (RRs) of patients requiring revision hammertoe

correction, compared with the study population as a whole, were statistically significantly higher in patients who underwent an metatarsophalangeal joint capsulotomy (3.10 vs 0.97; RR, 3.20) and those who experienced K-wire-related complications (5.10 vs 1.80, RR, 2.84)

No attempt to formally repair plantar plate in those toes with MTP dislocation – 6-weeks of joint immobilization with K-wire allows sufficient scarring and stabilization of soft tissues

The cost of newer permanent toe implants can range from $500 to $1500 per implant. A K-wire typically costs between $10 and $40.

10/21/2016

18

Canales et al. JFAS 2014A Simple Method of Intramedullary Fixation for Proximal Interphalangeal

Arthrodesis


Arthrodesis

10/21/2016

19


Arthrodesis


Arthrodesis

10/21/2016

20


Arthrodesis

Hood et al. Foot & Ankle Specialist Diverging Dual Intramedullary Kirschner Wire Technique for Arthrodesis

of the Proximal Interphalangeal Joint in Hammertoe Correction

10/21/2016

21

Hood et al. Foot & Ankle Specialist Diverging Dual Intramedullary Kirschner Wire Technique for Arthrodesis

of the Proximal Interphalangeal Joint in Hammertoe Correction

Catena et al. FAI 2014Prospective Study of Hammertoe Correction With an Intramedullary

Implant

29 patients 53 toes (29-2nd, 15-3rd,

9-4th) – Smart Toe Implants

Mean age = 63 y/o21 F : 8 M

Mean F/U – 12 mos.

Weil osteotomy 74% (31/42) toes

MT resection 14% (6/42) toes

5 patients were lost to F/U

K-wire inserted across PIPJ and MPJ in 34 toes and PIPJ

only in 8 toes

A study by Lehman et al. (FAI 1995) after PIPJ fusion defined a satisfied patient as one with an overall AOFAS score of 80 or higher.

10/21/2016

22


Implant


Implant

10/21/2016

23

Role of MPJ Release 05

Dhukaram et al. JBJS (Br) 2002Correction of hammer toe with an extended release of the

metatarsophalangeal joint

10/21/2016

24



1. 84 patients (179 toes)2. Type 2 toes3. 69 patients for F/U4. Mean F/U = 28 mos.

Methods Results Results

1. AOFAS mean P/O = 83 (87% score > 60)

2. 83% satisfied 3. 17% dissatisfied

a) MTPJ pain 11/78 feet (14%)

a) 2 MTPJ instability (3%)

b) 7 callus formation (9%)

c) Poor alignment 10 (13%)



AOFAS < 2 years F/U = 83 & > 2 years F/U = 82

HAV correction AOFAS = 81.5

Isolated HDS AOFAS = 83

Number of toes corrected AOFAS 1 = 85; > 1 = 83

Male AOFAS = 80.5

Female AOFAS = 85

AOFAS < 55 y/o = 80

AOFAS > 55 y/o = 85

49 (71%) satisfied, 8 (12%) satisfied with reservations, 12 (17%) dissatisfied

48 (70%) recommend, 5 (7%) recommend with reservations, 16 (23%) wouldn’t

10/21/2016

25

Thank You

[email protected]

hammer digit syndrome an evidence based approachschd.ws/hosted_files/ipmafall2016/6e/hammer...

Documents